Healthcare Provider Details

I. General information

NPI: 1053658005
Provider Name (Legal Business Name): JAMIE KIM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2013
Last Update Date: 01/24/2022
Certification Date: 01/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10316 WOODLEY AVE
GRANADA HILLS CA
91344-6916
US

IV. Provider business mailing address

9535 RESEDA BLVD STE 304
NORTHRIDGE CA
91324-6029
US

V. Phone/Fax

Practice location:
  • Phone: 818-368-5651
  • Fax:
Mailing address:
  • Phone: 818-886-3884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: